Urban people's preferences for life-sustaining treatment or artificial nutrition and hydration in advance decisions.

BACKGROUND: The Patient Right to Autonomy Act (PRAA), implemented in Taiwan in 2019, enables the creation of advance decisions (AD) through advance care planning (ACP). This legal framework allows for the withholding and withdrawal of life-sustaining treatment (LST) or artificial nutrition and hydration (ANH) in situations like irreversible coma, vegetative state, severe dementia, or unbearable pain. This study aims to investigate preferences for LST or ANH across various clinical conditions, variations in participant preferences, and factors influencing these preferences among urban residents. METHODS: Employing a survey of legally structured AD documents and convenience sampling for data collection, individuals were enlisted from Taipei City Hospital, serving as the primary trial and demonstration facility for ACP in Taiwan since the commencement of the PRAA in its inaugural year. The study examined ADs and ACP consultation records, documenting gender, age, welfare entitlement, disease conditions, family caregiving experience, location of ACP consultation, participation of second-degree relatives, and the intention to participate in ACP. RESULTS: Data from 2337 participants were extracted from electronic records. There was high consistency in the willingness to refuse LST and ANH, with significant differences noted between terminal diseases and extremely severe dementia. Additionally, ANH was widely accepted as a time-limited treatment, and there was a prevalent trend of authorizing a health care agent (HCA) to make decisions on behalf of participants. Gender differences were observed, with females more inclined to decline LST and ANH, while males tended towards accepting full or time-limited treatment. Age also played a role, with younger participants more open to treatment and authorizing HCA, and older participants more prone to refusal. CONCLUSION: Diverse preferences in LST and ANH were shaped by the public's current understanding of different clinical states, gender, age, and cultural factors. Our study reveals nuanced end-of-life preferences, evolving ADs, and socio-demographic influences. Further research could explore evolving preferences over time and healthcare professionals' perspectives on LST and ANH decisions for neurological patients..

Factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients.

BACKGROUND: Inappropriate management of medications is a major threat to homebound patients with chronic conditions. Despite many efforts in improving medication reconciliation in ambulatory and inpatient settings, little research has focused on home care settings. In 2016, Taiwan initiated the Integrated Home Health Care programme, which was intended to reduce potentially inappropriate medication management and risks of uncontrolled polypharmacy through the integration of different medication sources for chronic conditions among homebound patients. This study investigated factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients. METHOD: This retrospective cohort study enrolled 3142 community-dwelling homebound patients from Taipei City Hospital. Homebound patients' adherence to using home care physicians as an integrated source of chronic condition medications was defined as having all prescriptions for their chronic conditions prescribed by a single home care physician for at least 6 months. Both patient and home care physician characteristics were analysed. Multivariable logistic regression was applied. RESULTS: Of the 3142 patients with chronic conditions, 1002 (31.9%) had consistently obtained all medications for their chronic illnesses from their home care physicians for 6 months and 2140 (68.1%) had not. The most common chronic diseases among homebound patients were hypertension, diabetes mellitus, dementia, cerebrovascular disease and constipation. Oldest-old patients with poor functional status, fewer daily medications, no co-payment exemption and no recent inpatient experience were more likely to adhere to this medication integration system. In addition, patients whose outpatient physicians were also their home care physicians were more likely to adhere to the system. CONCLUSIONS: The finding suggests that building trust and enhancing communication among homebound patients, caregivers and home care physicians are critical. Patient and provider variations highlight the need for further improvement and policy modification for medication reconciliation and management in home care settings. The improvement in medication management and care integration in home care settings may reduce misuse and polypharmacy and improve homebound patients' safety.

Pre-Injury headache and post-traumatic headache in patients with mild traumatic brain injury: neuropsychological, psychiatric, and post-concussion symptom outcomes.

PRIMARY OBJECTIVE: Headache, both before and after injury, has been associated with worse outcome following mild traumatic brain injury (MTBI). This study examined whether three MTBI patient groups - no headache (reported no pre-/post-injury headache), pre-injury headache (reported pre-injury headache, nearly all of whom also reported post-injury headache), and post-traumatic headache only (denied pre-injury headache and reported post-injury headache) - differed in acute-to-subacute outcomes. RESEARCH DESIGN: Cross-sectional observational study. METHODS AND PROCEDURES: Patients within 21 days of a MTBI (n = 291) completed neuropsychological tests and questionnaires evaluating depression, anxiety, and post-concussion symptoms. MAIN OUTCOMES AND RESULTS: Neuropsychological test performances did not differ between headache groups. Participants with pre-injury headache and participants with post-traumatic headache only reported greater change in self-reported physical and cognitive symptoms than participants with no headache. Participants with pre-injury headache reported worse post-injury anxiety symptoms than participants with post-traumatic headache only. CONCLUSIONS: The pre-injury headache and post-traumatic headache only groups did not meaningfully differ in outcome within 21 days of MTBI, but they had worse physical and cognitive symptoms than participants with no headache. Future research should assess whether differences in outcome emerge further from injury and whether specific headache subtypes are differentially associated with outcome.

Efficacy and cost-effectiveness analysis of post-acute care for elderly patients with hip fractures.

BACKGROUND/PURPOSE: Hip fractures are associated with physical dysfunction, and poor quality of life in the elderly. Post-acute care (PAC) would facilitate functional recovery in patients with hip fractures after surgeries. Taiwan has proposed a nationwide PAC program for hip fractures since 2017, but little has been known about its effectiveness. Therefore, this study aimed to evaluate the efficacy and cost-effectiveness of the PAC program for hip fracture patients in Taiwan. METHODS: This was a prospective study. Patients aged ≥ 65 years with hip fractures after surgeries were recruited and divided into home-based, hospital-based, and control groups. Outcome measures included pain, physical function (sit-to-stand test, Barthel Index [BI], and Harris hip score [HHS]), and quality of life (EuroQol instrument [EQ-5D]). Direct medical and non-medical costs were recorded. Cost-effectiveness ratio (CER) was calculated as the amount of New Taiwanese Dollars (NTDs) paid per BI and EQ-5D unit improvement. RESULTS: Forty-one patients participated in this study, with 17, 12, and 12 in the home-based, hospital-based, and control groups, respectively. The home-based group showed significant improvements in BI and HHS compared to the controls (p = 0.018 and p = 0.029, respectively). The hospital-based group demonstrated significant improvement in EQ-5D compared to the controls (p = 0.015). The home-based PAC program demonstrated the best CER for BI (NTD 554) and EQ-5D (NTD 41948). CONCLUSION: Both PAC programs would significantly improve the physical function and quality of life in patients with hip fractures. However, the home-based PAC provided the best CER for BI and EQ-5D.

Prompt successful response to a COVID-19 outbreak: Performance of community-based rapid screening station.

An outbreak occurred in Wanhua District of Taipei City. It was traced to a cluster infection originating from a teahouse. To prevent further large-scaled community spread, the Taipei City Government established the first community rapid test screening station. This report describes the station's strategy and performance and key factors that contributed to its operation. The project involves collaboration among various departments of Taipei City Government, including the health, environmental, police, transportation, and fire departments. The station provides rapid screening, polymerase chain reaction (PCR) testing, and immediate isolation and follow-up medical services upon the detection of a positive case. These services are accessible to local residents and are intended to ease hospitals' burdens. In 36 days, a total of 8532 people were tested, and 419 confirmed cases were identified. Over the same period, the weekly number of positive cases in Wanhua District decreased from 356 to 40, and the PCR positive rate decreased from 21.7% to 1.2%. The policy of establishing rapid screening station, contact tracing and mask wearing policy are key strategies for interrupting chains of transmission of COVID-19. This intervention has become a model for preventing the spread of the epidemic and establishing community rapid screening stations in Taiwan.

Advance Care Planning Among Adult Patients and Their End-of-Life Care Preferences.

To explore people's intentions to opt for a good death when planning for their end-of-life care, this study examined the type of end-of-life care preferred by patients receiving advance care planning (ACP) consulting services for five specified clinical and disability conditions and possible factors affecting their decision-making. This cross-sectional study analyzed 1303 hospital patients and 1032 nonhospital patients who attended a clinic providing ACP consulting services. This study revealed the following two results. First, patients who were older, were female, did not have an appointed surrogate decision-maker, and were nonhospital patients had a higher intention of not receiving life-sustaining treatments (LST) or artificial nutrition and hydration (ANH) under the five specified clinical and disability conditions. Second, people who were the least willing to receive LST or ANH under the following conditions (in descending order): permanent vegetative state, severe dementia, irreversible coma, other disease conditions recognized by the central competent authority, and end-of-life stage.

A-qCPR risk score screening model for predicting 1-year mortality associated with hospice and palliative care in the emergency department.

BACKGROUND: Evaluating the need for palliative care and predicting its mortality play important roles in the emergency department. AIM: We developed a screening model for predicting 1-year mortality. DESIGN: A retrospective cohort study was conducted to identify risk factors associated with 1-year mortality. Our risk scores based on these significant risk factors were then developed. Its predictive validity performance was evaluated using area under receiving operating characteristic analysis and leave-one-out cross-validation. SETTING AND PARTICIPANTS: Patients aged 15 years or older were enrolled from June 2015 to May 2016 in the emergency department. RESULTS: We identified five independent risk factors, each of which was assigned a number of points proportional to its estimated regression coefficient: age (0.05 points per year), qSOFA ⩾ 2 (1), Cancer (4), Eastern Cooperative Oncology Group Performance Status score ⩾ 2 (2), and Do-Not-Resuscitate status (3). The sensitivity, specificity, positive predictive value, and negative predictive value of our screening tool given the cutoff larger than 3 points were 0.99 (0.98-0.99), 0.31 (0.29-0.32), 0.26 (0.24-0.27), and 0.99 (0.98-1.00), respectively. Those with screening scores larger than 9 points corresponding to 64.0% (60.0-67.9%) of 1-year mortality were prioritized for consultation and communication. The area under the receiving operating characteristic curves for the point system was 0.84 (0.83-0.85) for the cross-validation model. CONCLUSIONS: A-qCPR risk scores provide a good screening tool for assessing patient prognosis. Routine screening for end-of-life using this tool plays an important role in early and efficient physician-patient communications regarding hospice and palliative needs in the emergency department.

Resection of swollen temporal muscles in patients with intractable intracranial hypertension after decompressive craniectomy.

BACKGROUND: Decompressive craniectomy is employed as treatment for traumatic brain swelling in selected patients. We discussed the effect of temporal muscle resection in patients with intractable intracranial hypertension and temporal muscle swelling after craniectomy. METHODS: Records of 280 craniectomies performed on 258 patients who were admitted with severe head injury were retrospectively reviewed. Eight patients developed intractable increased intracranial pressure with temporal muscle swelling within 24 h after craniectomy and were treated by muscle resection. RESULTS: The initial Glasgow Coma Scale score was 7 ± 1. The mean intracranial pressure was 41.7 ± 8.59 mmHg before muscle resection and 14.81 ± 8.07 mmHg immediately after surgery. Five patients had skull fracture and epidural hematoma at the craniectomy site. The mean intensive care unit stay was 11.25 ± 5.99 days. Glasgow Outcome Scale-Extended scoring performed during the 12-month follow-up visit showed that 6 patients (75%) had a favorable outcome. CONCLUSIONS: Our study findings indicate that a direct impact on the temporal region during trauma may lead to subsequent temporal muscle swelling. Under certain circumstances, muscle resection can effectively control intracranial pressure.

Excess mortality and risk factors for mortality among patients with severe mental disorders receiving home care case management.

AIM: Home care case management (CM) is the main intervention for patients with severe mental disorders (SMDs) requiring outreach care. This study investigated the long-term mortality outcome and associated risk factors in patients who received home care CM. METHODS: This nationwide study enrolled patients who received home care CM (n = 10,255) between 1 January 1999 and 31 December 2010. Each patient was followed up from the baseline (when patients underwent home case CM for the first time during the study period) to the censor (i.e. mortality or the end of the study). We calculated the standardized mortality ratio (SMR) and presented by age and diagnosis. Multivariate regression was performed to assess independent risk factors for mortality. RESULTS: Among 10,255 patients who received home care CM, 1409 died during the study period; the overall SMR was 3.13. Specifically, patients with organic mental disorder had the highest SMR (4.98), followed by those with schizophrenia (3.89), major depression (2.98), and bipolar disorder (1.97). In the multivariate analysis, patients with organic mental disorder or dementia had the highest risk, whereas the mortality risk in patients with schizophrenia was comparable to that in patients with bipolar disorder or major depression. Deceased patients had a significantly higher proportion of acute or chronic physical illnesses, including cancer, chronic hepatic disease, pneumonia, diabetes mellitus, cardiovascular disease, and asthma. CONCLUSION: This study presented the gap of mortality in patients with SMDs receiving home care CM in Taiwan. We highlight the need for effective strategies to improve medical care for this specified population.

Use and Cost-Effectiveness of a Telehealth Service at a Centralized COVID-19 Quarantine Center in Taiwan: Cohort Study.

BACKGROUND: Telehealth is a recommended method for monitoring the progression of nonsevere infections in patients with COVID-19. However, telehealth has not been widely implemented to monitor SARS-CoV-2 infection in quarantined individuals. Moreover, studies on the cost-effectiveness of quarantine measures during the COVID-19 pandemic are scarce. OBJECTIVE: In this cohort study, we aimed to use telehealth to monitor COVID-19 infections in 217 quarantined Taiwanese travelers and to analyze the cost-effectiveness of the quarantine program. METHODS: Travelers were quarantined for 14 days at the Taiwan Yangmingshan quarantine center and monitored until they were discharged. The travelers' clinical symptoms were evaluated twice daily. A multidisciplinary medical team used the telehealth system to provide timely assistance for ill travelers. The cost of the mandatory quarantine was calculated according to data from the Ministry of Health and Welfare of Taiwan. RESULTS: All 217 quarantined travelers tested negative for SARS-CoV-2 upon admission to the quarantine center. During the quarantine, 28/217 travelers (12.9%) became ill and were evaluated via telehealth. Three travelers with fever were hospitalized after telehealth assessment, and subsequent tests for COVID-19 were negative for all three patients. The total cost incurred during the quarantine was US $193,938, which equated to US $894 per individual. CONCLUSIONS: Telehealth is an effective instrument for monitoring COVID-19 infection in quarantined travelers and could help provide timely disease management for people who are ill. It is imperative to screen and quarantine international travelers for SARS-CoV-2 infection to reduce the nationwide spread of COVID-19.

Validation of a concise screening tool for the identification of palliative care needs among inpatients: A prospective study in hospital setting.

BACKGROUND/PURPOSE: Very few studies have investigated the screening tools that aim to identify the need of palliative care services among patients with advanced cancer or chronic non-malignant diseases. This study validated the one-page Taiwanese version-Palliative Care Screening Tool (TW-PCST) for screening inpatients with potential palliative care needs. METHOD: ROC curves were produced to examine the sensitivities and specificities at varying cut-off points. The optimal cut-off value to predict mortality was justified using the Youden's index. The screening was conducted on the first day of admission. Patients were prospectively followed-up after the baseline assessment. Three followed-up periods, namely 14 days, 90 days, and 180 days were analyzed. RESULTS: A total of 21,596 patients were screened. AUCs for all cut-off scores varied from 0.84 to 0.88. A total-ABCD score ≥2 gave the highest Youden's index for 90 days and 180 days follow-up periods. The optimal cut-point for 14 days was score ≥3. CONCLUSION: The TW-PCST demonstrated a good sensitivity and specificity in identification of inpatients with palliative care needs. A total-ABCD score ≥2 may be considered as a trigger for further referral.

[The Promotion of Resources Integration in Long-Term Care Service: The Experience of Taipei City Hospital].

The home-based medical care integrated plan under Taiwan National Health Insurance has changed from paying for home-based medical care, home-based nursing, home-based respiratory treatment, and palliative care to paying for a single, continuous home-based care service package. Formerly, physician-visit regulations limited home visits for home-based nursing to providing medical related assessments only. This limitation not only did not provide practical assistance to the public but also caused additional problems for those with mobility problems or who faced difficulties in making visits hospital. This 2016 change in regulations opens the door for doctors to step out their 'ivory tower', while offering the public more options to seek medical assistance in the hope that patients may change their health-seeking behavior. The home-based concept that underlies the medical service system is rooted deeply in the community in order to set up a sound, integrated model of community medical care. It is a critical issue to proceed with timely job handover confirmation with the connecting team and to provide patients with continuous-care services prior to discharge through the discharge-planning service and the connection with the connecting team. This is currently believed to be the only continuous home-based medical care integrated service model in the world. This model not only connects services such as health literacy, rehabilitation, home-based medical care, home-based nursing, community palliative care, and death but also integrates community resources, builds community resources networks, and provides high quality community care services.

Determinants of Receiving Palliative Care and Ventilator Withdrawal Among Patients With Prolonged Mechanical Ventilation.

OBJECTIVES: Increasing numbers of patients with prolonged mechanical ventilation generates a tremendous strain on healthcare systems. Patients with prolonged mechanical ventilation suffer from long-term poor quality of life. However, no study has ever explored the willingness to receive palliative care or terminal withdrawal and the factors influencing willingness. DESIGN: Cross-sectional study. SETTING: Five different hospitals of Taipei City Hospital system. PATIENTS: Adult patients with ventilatory support for more than 60 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified the family members of 145 consecutive patients with prolonged mechanical ventilation in five hospitals of Taipei City Hospital system and enrolled family members for 106 patients (73.1%). We collected information from patient families' regarding concepts (knowledge, attitude, and experiences) of palliative care, caregiver burden, family function, patient quality of life, and physician-family communications. From the medical record, we obtained duration of hospitalization, consciousness level, disease severity, medical cost, and the presence of do-not-resuscitate orders. The vast majority of family members agreed with the concept of palliative care (90.4%) with 17.3% of the family members agreeing to ventilator withdrawal currently and 67.5% terminally in anticipation of death. Approximately half of the family members regretted having chosen prolonged mechanical ventilation (56.7%). Reduced patient quality of life and increased family understanding of palliative care significantly associated with increased caregiver willingness to endorse palliative care and withdraw life-sustaining agents in anticipation of death. Longer duration of ventilator usage and hospitalization was associated with increased feelings of regret about choosing prolonged mechanical ventilation. CONCLUSIONS: During prolonged mechanical ventilation, physicians should thoroughly discuss its benefits and burdens. Families should be given the opportunity to discuss the circumstances under which they might request the implementation of palliative care or withdrawal of mechanical ventilation in order to avoid prolonging the dying process.

Quality of return to work in patients with mild traumatic brain injury: a prospective investigation of associations among post-concussion symptoms, neuropsychological functions, working status and stability.

PRIMARY OBJECTIVE: Although 'return to work' (RTW) has been always emphasized for patients with mild traumatic brain injury (MTBI), methodological drawbacks weakened its representativeness. This study thus aims to evaluate the 'work quality' (WQ) which originated from 'working status' and 'working stability' simultaneously, and to further explore the associations among post-concussion symptoms (PCS), neuropsychological functions and WQ. METHODS AND PROCEDURES: A total of 179 participants, which included 132 patients with MTBI and 47 healthy participants, were prospectively recruited. The work quality index (WQI) was developed to evaluate WQ. All patients were evaluated for their PCS, neuropsychological functions and WQ at two weeks post-injury (T1), while PCS and WQ were recorded by one month post-injury (T2). RESULTS: More than half of the patients were not able to retain their pre-injury jobs at T1, while 26% of the patients still failed to regain previous works at T2. Interestingly, WQ was significantly associated with educational levels and physical PCS, such as headache and dizziness. CONCLUSIONS: Simultaneously considering working status and stability to reveal the quality of RTW is merited. A higher educational level might be a protective factor for successful RTW, and ameliorating physical symptoms is also necessary to get favourable WQ by one month after MTBI.

Establishment of a renal supportive care program: Experience from a rural community hospital in Taiwan.

Renal supportive care (RSC) denotes a care program dedicated for patients with acute, chronic renal failure, and end-stage renal disease (ESRD), aiming to offer maximal symptom relief and optimize patients' quality of life. The uncertainty of prognosis for patients with chronic kidney disease and ESRD, the sociocultural issues inherent to the Taiwanese society, and the void of structured and practical RSC pathway, contributes to the underrecognition and poor utilization of RSC. Taiwanese patients rarely receive information regarding RSC as part of a standardized care and are not commonly offered this option. In National Taiwan University Hospital Jinshan branch, we started a RSC subprogram, supported by the community-based palliative/hospice care main program. We focused on understanding the need and providing the choice of RSC to suitable candidates. A three-step and four-phase protocol was designed and implemented to identify appropriate patients and to enhance the applicability of the RSC. We harnessed family visit and home-based family meeting as a vehicle to understand the patients' preferences, to discover what ESRD patients and their family value most, and to introduce the option of RSC. In the current review, we described our pilot experience of establishing a RSC program in Taiwan, and discuss its potential advantage.

Intrathecal lactate predicting hydrocephalus after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Evidence shows possible benefits from continuous drainage by lumbar drain after aneurysmal subarachnoid hemorrhage (SAH). Under the hypothesis that compartmentalization occurs between the ventricle and subarachnoid space after massive SAH, this study aimed to evaluate the biochemical differences between ventricular and intrathecal cerebrospinal fluid (CSF) and assess the role of CSF lactate in shunt-dependent hydrocephalus (SDHC) after aneurysmal SAH. MATERIALS AND METHODS: Patients with modified Fisher grade III/IV aneurysmal SAH who underwent early obliteration were evaluated. Intrathecal and intraventricular CSF were obtained on day 7 post-SAH to measure their biochemical composition in terms of total protein, glucose, ferritin, and lactate. The associations of SDHC with the clinical parameters and CSF data were analyzed. RESULTS: There were 28 patients (mean age, 55.4 y; males, 46.6%), including 18 (64.3%) with SDHC. Intrathecal CSF had significantly higher levels of total protein, ferritin, hemoglobin, and lactate but lower glucose level than intraventricular CSF (all P < 0.0001). By multivariate analysis of clinical and CSF parameters, elevated intrathecal CSF lactate (P = 0.036) and the presence of intraventricular hemorrhage (P = 0.05) were independent factors associated with SDHC. Moreover, intrathecal lactate >5.5 µM effectively predicted the occurrence of SDHC (odds ratio: 32, 95% confidence interval: 3.8-270.8; P = 0.0015). CONCLUSIONS: By compartmentalization of the subarachnoid space after SAH, intrathecal lactate level is a useful predictive parameter for long-term SDHC in patients with aneurysmal SAH patients.

Effect of mannitol on cerebrovascular pressure reactivity in patients with intracranial hypertension.

BACKGROUND/PURPOSE: Mannitol is commonly used in patients with increased intracranial pressure (ICP), but its effect on cerebrovascular pressure reactivity (CVPR) is uncertain. We analyzed the changes of pressure reactivity index (PRx) during the course of mannitol treatment. METHODS: Twenty-one patients who received mannitol treatment for increased ICP were recruited prospectively. Continuous waveforms of arterial blood pressure (ABP) and ICP were collected simultaneously for 60 minutes (10 minutes at baseline and 50 minutes since mannitol administration) during 37 events of mannitol treatment. The correlation coefficients between the mean ABP and ICP were averaged every 10 minutes and labeled as the PRx. The linear correlation of six time points of PRx in each event was calculated to represent the trend of CVPR changes. The negative slope of correlation was defined as improvement in CVPR under mannitol treatment and vice versa. RESULTS: At baseline, the average of ICP was 26.0 ± 9.1 mmHg and the values of PRx were significantly correlated with ICP (p = 0.0044, r = 0.46). After mannitol administration, the average of ICP decreased significantly to 21.2 ± 11.1 mmHg (p = 0.036), and CVPR improved in 59.4 % of all events. Further analysis showed that low baseline cerebral perfusion pressure was the only hemodynamic parameter significant association with the improvement of CVPR after mannitol treatment (p = 0.039). CONCLUSION: Despite lowering ICP, mannitol may have diverse effects on CVPR in patients with intracranial hypertension. Our study suggests that mannitol infusion may have a beneficial effect on CVPR, particularly in those with a low cerebral perfusion pressure at baseline.

[The present and future of community/home-based palliative care in Taiwan].

In Taiwan, the Department of Health (DOH) has implemented regulations and policies related to hospice and palliative care since 1995. Taiwan is the first country in Asia to have a Natural Death Act, promulgated in 2000. Although recognition of the need for palliative care in non-cancer terminally ill patients is increasing, at present, the needs of these patients are often not met. Moreover, while a majority of the population prefers to die at home, the percentage of patients who die in the home setting remains small. The palliative care system should be adjusted to improve the accessibility and continuity of care based on the needs of patients. Therefore, the Jin-Shan Branch of the National Taiwan University Hospital has run a pilot community palliative care service model since 2012. National Health Insurance reimbursement was introduced in 2014 for community-based palliative care services. Establishing a formal system of community-based palliative care should be encouraged in order to improve the quality of care at the end of life and to allow more patients to receive end-of-life care and die in their own communities. This system will require that skilled nurses provide discharge planning, symptoms control, end-of-life communications, social-resources integration, and social-support networks in order to achieve a high quality of end-of-life care.

Incidence, life expectancy and prognostic factors in cancer patients under prolonged mechanical ventilation: a nationwide analysis of 5,138 cases during 1998-2007.

INTRODUCTION: This study is aimed at determining the incidence, survival rate, life expectancy, quality-adjusted life expectancy (QALE) and prognostic factors in patients with cancer in different organ systems undergoing prolonged mechanical ventilation (PMV). METHODS: We used data from the National Health Insurance Research Database of Taiwan from 1998 to 2007 and linked it with the National Mortality Registry to ascertain mortality. Subjects who received PMV, defined as having undergone mechanical ventilation continuously for longer than 21 days, were enrolled. The incidence of cancer patients requiring PMV was calculated, with the exception of patients with multiple cancers. The life expectancies and QALE of patients with different types of cancer were estimated. Quality-of-life data were taken from a sample of 142 patients who received PMV. A multivariable proportional hazards model was constructed to assess the effect of different prognostic factors, including age, gender, type of cancer, metastasis, comorbidities and hospital levels. RESULTS: Among 9,011 cancer patients receiving mechanical ventilation for more than 7 days, 5,138 undergoing PMV had a median survival of 1.37 months (interquartile range [IQR], 0.50 to 4.57) and a 1-yr survival rate of 14.3% (95% confidence interval [CI], 13.3% to 15.3%). The incidence of PMV was 10.4 per 100 ICU admissions. Head and neck cancer patients seemed to survive the longest. The overall life expectancy was 1.21 years, with estimated QALE ranging from 0.17 to 0.37 quality-adjusted life years for patients with poor and partial cognition, respectively. Cancer of liver (hazard ratio [HR], 1.55; 95% CI, 1.34 to 1.78), lung (HR, 1.45; 95% CI, 1.30 to 1.41) and metastasis (HR, 1.53; 95% CI, 1.42 to 1.65) were found to predict shorter survival independently. CONCLUSIONS: Cancer patients requiring PMV had poor long-term outcomes. Palliative care should be considered early in these patients, especially when metastasis has occurred.

Divergent manifestations of irritability in patients with mild and moderate-to-severe traumatic brain injury: perspectives of awareness and neurocognitive correlates.

PRIMARY OBJECTIVES: To evaluate irritability in patients with mild traumatic brain injury (mTBI) and moderate-to-severe traumatic brain injury (msTBI), respectively. RESEARCH DESIGN: A prospective study was conducted at a level I trauma centre. METHODS AND PROCEDURES: A total of 160 participants, which included 80 healthy subjects and 80 patients with TBI, were recruited. Irritability was assessed by the National Taiwan University Irritability Scale and other cognitive functions, which included memory, executive function and information processing, were also evaluated. MAIN OUTCOMES AND RESULTS: The results showed post-injury self-reported irritability in patients with mTBI and family-reported irritability in patients with msTBI were significantly higher than irritability reported by healthy participants. Irritability was significantly associated with information processing ability in patients with mTBI, but it was not associated with any cognitive functions in patients with msTBI. CONCLUSIONS: Irritability was found to be prominent after TBI. Divergent causes of irritability seemed apparent in patients with mTBI and msTBI. Irritability after mTBI appeared might be related to the cognitive functions disrupted after the injury, whereas irritability after msTBI appeared to result directly from the brain lesions involved.